Form Dhcs 7098 - California Staying Healthy Assessment (Tagalog) - Health And Human Services Agency Page 2
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1
2
3State of California – Health and Human Services Agency
Department of Health Care Services
HuwagSa
Hi ndi
Oo
gutin
Nagpapalipaskabangorasna may kasamangnagdadalangbaril,
12
kutsilyo, o iba pang armas?
HuwagSa
No
Yes
Oo
Hi ndi
Spends time with anyone who carries a gun, knife, or other weapon?
Skip
gutin
Ikawba ay palaginggumagamitng helmet kung
13
HuwagSa
sumasakaysabisekleta, skateboard, o scooter?
Hi ndi
Oo
Yes
No
gutin
Always wears a helmet when riding a bike, skateboard, or scooter?
Skip
Ikawba ay naging testigo nangpang-aabuso o bayulente?
14
HuwagSa
Ever witnessed abuse or violence?
No
Yes
Hi ndi
Oo
Skip
gutin
Ikawba ay tinamaan, sinampal, tinadyakan, o sinaktansapisikalng
15
kung sinosaloobnoongisangtaon?
Been hit, slapped, kicked, or physically hurt
No
Yes
HuwagSa
by someone (or has he/she hurt someone) in the past year?
Skip
Hi ndi
Oo
gutin
Natuksokanaba o may pakiramdamka bang
hindiligtassaeskuwelahan o saiyongkumyunidad (o na cyber
16
HuwagSa
No
Yes
bullied)?
Oo
Hi ndi
Skip
gutin
Ever been bullied or felt unsafe at school/neighborhood (or been cyber-bullied)?
D e n t a l H e a l t h
Ikawba ay nagsisipilyo at nag-flo-floss ngiyongngipinaraw-araw?
HuwagSa
17
Hi ndi
Oo
Brushes and flosses teeth daily?
Yes
No
gutin
Skip
M e n t a l H e a l t h
Palagikabangnakakaramdamngkalungkutan, pagka baba, o
18
HuwagSa
Hi ndi
Oo
kawalanngpag-asa?
No
Yes
Often feels sad, down, or hopeless?
gutin
Skip
Alcohol, Tobacco,
19
Nagpapalipaskabanyoraskasamaangisangnaninigarilyo?
Drug Use
HuwagSa
Hi ndi
Oo
No
Yes
Spends time with anyone who smokes?
gutin
Skip
20
Naninigarilyokabangsigarilyo o ngumunguyangtabako?
No
Yes
Smokes cigarettes or chews tobacco?
HuwagSa
Skip
Hi ndi
Oo
gutin
Gumagamitkaba o umaamoynganomangsubstansiyaparamaging
21
high, gayang marijuana, cocaine, crack, Methamphetamine
No
Yes
(meth), ecstasy, etc.?
HuwagSa
Skip
Hi ndi
Oo
Uses or sniffs any substance to get high?
gutin
Gumagamit ka ba ng mga gamot na hindi iniresita para sa iyo?
HuwagSa
22
Hi ndi
Oo
Uses medicines not prescribed for her/him?
No
Yes
gutin
Skip
Umiinomkabangalkoholisangbesessaisanglinggo o masmadami?
23
HuwagSa
Drinks alcohol once a week or more?
No
Yes
Hi ndi
Oo
Skip
gutin
Kung umiinomkangalkohol,
umiinomkabangmasmaramihanggangikaw ay malasing o
24
No
Yes
mahimatay?
HuwagSa
Skip
Hi ndi
Oo
If she/he drinks alcohol, drinks enough to get drunk or pass out?
gutin
Mayroonkabangmgakaibigan o mgamiyembrongpamilyanamay
25
problema samga droga o alkohol?
No
Yes
HuwagSa
Has friends/family members who have problems with drugs or alcohol?
Skip
Hi ndi
Oo
gutin
Nagmamanehokabangkotsepagkataposkanguminom, o
sumasakaysakotsenaminamanehongumiinom o
26
HuwagSa
No
Yes
gumagamitngmgadroga?
Drives a car after drinking, or rides in a car driven by
Hi ndi
Oo
Skip
gutin
someone who has been drinking or using drugs?
Ikawba ay minsannangpinilit o
S e x u a l I s s u e s
27
naubliganamagkaroonngpakikipagtalik?
HuwagSa
No
Yes
Hi ndi
Oo
Ever been forced or pressured to have sex?
Skip
gutin
Nagkaroonkanabangpakikipagtalik (oral, vaginal, o anal)?
28
Kung hindi, sagutinangtanongsanumero 35.
No
Yes
Ever had sex (oral, vaginal, or anal)?
Skip
DHCS 7098 G TAGALOG (12/14)
SHA (12 – 17 Years)
Page 2 of 3
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